Declaration Form

Radiant Glow Beauty Care — Official Digital Client Consultation & Consent Form

Radiant Glow

Radiant Glow Beauty Care

CLIENT CONSULTATION & DECLARATION FORM

Section 1: Client Personal Details & Identification
Section 2: Medical History & General Analysis

Please tick any conditions that apply to you. All details are kept strictly confidential.

Contra-Indication: (Consent To Be Signed)
Contra-Indication: (treatment should be restricted)
Section 3: Consent for Treatment & Declaration

Consent for Laser Hair Removal / Treatment :

I, [Client Full Name] (patient's name), authorize the technicians at Radiant Glow Beauty Care to perform Laser Hair Reduction treatment(s) on me. There are several alternatives to laser hair removal including but not limited to electrolysis, shaving, waxing and plucking or no treatment at all.
Legal Compliance Notice: By providing your digital signature and ticking the consent box, this declaration is legally registered and transmitted to the Radiant Glow Pune Clinic database.
All medical data is stored securely under strict clinical confidentiality.

Radiant Glow Beauty Care

CLIENT CONSULTATION FORM

Client's name:
Address:
Gender: Male Female Client's ID / Aadhar:
Profession:
Contact Details: PH: M / Email:
Date: Treatment:
PERSONAL DETAILS:
Age Group: under 20 20-30 30-40 40-50 50-60 60+
MEDICAL HISTORY AND GENERAL ANALYSIS
Contra-Indication: (Consent To Be Signed)
Pregnancy Recent Operations
Heart Conditions Asthma
Hypertension/Hypotension Bell's Palsy
Any condition currently observed by GP or Dermatologist History of Cancer
Nervous client Undiagnosed Pain
Diabetes Prescribed Medication
Epilepsy Others
Contra-Indication: (treatment should be restricted)
Fever Contagious/Infectious diseases
skin allergies skin cancer
Hepatitis Undiagnosed lumps/bumps
Hypersensitive skin Broken Capillaries
Localised sweling Inflammation
Cuts Bruises
Sun burn Scar tissu
Recent fractures Any Metal Pin/plates
Loss of skin sensations Botox or Dermal Fillers (1wk following)

Consent for Laser Hair Removal / Treatment :

I, ______________________________ (patient's name), authorize the technicians at Radiant Glow Beauty Care to perform Laser Hair Reduction treatment(s) on me. There are several alternatives to laser hair removal including but not limited to electrolysis, shaving, waxing and plucking or no treatment at all.

I understand that serious complications are rare but Possible. Common side effects include temporary redness, swelling and mild "sunburn" like effects that may last a few hours to 3-4 days or longer on the treated area. Other potential risks include itching, pain, bruising, burns, infection, scabbing, blistering, hypopigmentation, hyperpigmentation, scarring, and failure to achieve the desired result(s).

I understand that a single procedure will most likely fail to completely remove all unwanted hair on the treated area. Multiple treatments are required. Individual response will vary according to skin types, hair color, degree of tanning, follow up care, and the body area being treated.

I understand that treatment can be painful, but this is typically managed without any pain relief medication. Discomfort generated by that laser pulse is most commonly described as a rubber band snapping against the skin. Topical anesthetics are available to decrease any perceived discomfort. Color changes, such as hyperpigmentation (brown/red discoloration) or hypopigmentation (skin lightening), may occur in the treated skin. This may take several months to resolve, if at all. Unprotected sun exposure in the weeks following treatments is contraindicated as it may cause or worsen this condition. Blistering of the skin may occur. Scarring happens but is uncommon..

Lasers can cause eye injury and protective eyewear must be worn during treatment.
I understand that sun or tanning lamp exposure and not adhering to the post-care Instructions provided to me may increase my chances of complications.
I understand that no refunds will be given for treatments or for treatments paid in advance.

I have read, been explained and understand as well as given the post-treatment instructions.

Client's Signature & Date
Radiant Glow Pune
Authorized Clinic Signature
Shop No 10, Ultima Business Centre, Kondhwa, Pune